Over the last 2 weeks, how often have you been bothered by any of the following problems? (Check the box that best fits your answer)

1. Little interest or pleasure in doing things
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

2. Feeling down, depressed, or hopeless
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

3. Trouble falling or staying asleep, or sleeping too much
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

4. Feeling tired or having little energy
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

5. Poor appetite or overeating
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

7. Trouble concentrating on things such as reading the newspaper or watching television
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

10. If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
(0) Not difficult at all(1) Somewhat difficult(2) Very difficult(3) Extremely difficult

PART II: GAD-7 Scale: Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious or on edge
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

2. Not being able to stop or control worrying
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

3. Worrying too much about different things
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

4. Trouble relaxing
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

5. Being so restless it's hard to sit still
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

6. Becoming easily annoyed or irritable
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

7. Feeling afraid as if something awful might happen.
(0) Not at all(1) Several days(2) More than half the days(3) Nearly every day

8. If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
(0) Not difficult at all(1) Somewhat difficult(2) Very difficult(3) Extremely difficult

Your Email

Your first and last name

Best phone # to reach you

Have you ever been seen at Oasis? yesno
If "Yes," have you been here in the last 2 years? yesnoI don't remember
In what year approximately did you last visit take place? N/A

I have read the consent form and agree to have my answers evaluated by a clinical psychologist and understand I will be contacted with the results within the next 7 days